Reducing harm, preventing HIV, saving lives: China’s vast methadone maintenance treatment program marks successes even as it addresses key challenges ahead

Feature story

Over barely a decade, China has built the world’s largest methadone maintenance treatment network, globally recognized as a leader in significantly reducing HIV and other infections among injecting drug users. But even as China marks this success, the government is seeking to partner more closely with civil society organizations to address the challenges that remain, to help ensure long-term sustainability and lasting impact.

Backdrop

In the early years of China’s HIV epidemic, needle and syringe sharing behaviours among drug users caused the virus to spread in Yunnan Province bordering Myanmar in the southwest, and from there to neighboring provinces via drug-trafficking routes at an alarming rate. As of 2002, all 31 provinces in mainland China had reported cases of HIV infection due to high-risk behaviours associated with injecting drug use.

“China had 70,000 registered drug users in 1990, and almost 2.5 million in 2013,” noted Dr Wu Zunyou, Director of China’s National Center for AIDS/STD Control and Prevention. “Even factoring for better surveillance over the years, this is still a staggering increase. While our epidemic today is concentrated more in other key populations, including men who have sex with men, the injecting drug use scenario remains a formidable challenge. ”

By the end of 2011, approximately 780,000 people were estimated to be living with HIV/AIDS nationwide, with 28.4% of infections attributed to injecting drug use. Among the 48,000 estimated new infections during 2011, transmission through injecting drug use accounted for 18%. It is estimated that HIV prevalence among the general population in China was 0.058% in 2011, but much higher among DUs overall -- 5% to 8% nationally but over 50% in some regions, such as Yunnan and Xinjiang (in the northwest).

Bold steps, bold partnerships

“Given the severity of the crisis that existed more than ten years ago, and despite the huge controversy surrounding drug use, we had to act quickly and boldly,” said Dr Wu. “Amid much internal debate involving government and law enforcement authorities, we introduced the first few methadone maintenance treatment programmes for drug users in Yunnan and four other provinces in 2004.”

Methadone maintenance treatment (MMT) involves the long-term prescribing of methadone (usually taken orally) as an alternative to the opioid (drug) on which the patient is dependent. MMT calls for providing counselling, case management and other medical and psychosocial services.

From just eight pilot MMT clinics ten years ago, China’s program began its rapid expansion in 2006. As of August 2014, there were 765 MMT clinics, including 29 MMT vans, operating in 28 provinces, autonomous regions and municipalities. In addition, to enhance the reach of MMT programs, more than 300 small MMT extension sites based on community healthcare centers in urban areas and township hospitals in rural areas were set up nationwide. Currently, China’s MMT program is the largest single MMT program in the world, serving more than 410,000 opiate users cumulatively since the first clinic opened in March 2004.

“The way in which China has scaled up its MMT program is nothing short of remarkable,” said Dr Bernhard Schwartlander, WHO Representative in China. “And what’s really important is that it’s an approach where the government, police, and other authorities work closely with drug users themselves, and organizations that represent them, to ensure their acceptance and buy in, and help to build trust and transparency over time.”

One such NGO is AIDS Care China, a past winner of the UN Red Ribbon Award and a longtime partner of China’s national and provincial health authorities in HIV/AIDS programs and interventions for key populations, including injecting drug users.

“We’ve worked extensively with government and law enforcement authorities in helping implement and assess MMT programs in Yunnan Province and elsewhere,” said Thomas Cai, Founder and Executive Director of AIDS Care China. “It’s only by joining hands with NGOs on the frontlines that government programs can ensure maximum impact. The government has realized this, and has reached out more and more to civil society partners to involve key populations in seeking solutions to long-running crises.”

Robust evaluation, proven impact

WHO guidelines have endorsed MMT as the mainstay of opioid dependence treatment. It’s been shown to reduce premature mortality by two thirds and opioid overdose mortality tenfold. Further, it dramatically reduces illicit opioid use, crime and HIV spread, and improves adherence to HIV, TB and hepatitis treatment. Since the first studies of methadone treatment were published in the 1960s, methadone has been used extensively for the treatment of opioid dependence and has saved millions of lives worldwide. (Link: http://www.who.int/bulletin/volumes/90/3/12-101881/en/)

China’s MMT program follows an outpatient model. Clients attend clinics daily to obtain their methadone dose, under the direct observation of clinic staff. There is no option for take-home doses, nor any legal way to obtain methadone outside the clinics.

A baseline survey is conducted within one month after enrollment to collect data on drug abuse, sexual and criminal history, and social functioning. A blood sample is taken to assess HIV, hepatitis C and syphilis status. A follow-up survey is scheduled for six months post-enrollment at which time clients’ satisfaction with the MMT service is also measured. A web-based system, the National MMT Data Management System, was set up in 2008, which simplified the data management and data analysis process and facilitated the monitoring and evaluation of the program.

According to NCAIDS data, since the introduction of the MMT program, HIV incidence among MMT clients has dramatically decreased by over 80% from 2006 to 2013.

A conservative estimate suggests that about 13,000 HIV infections were prevented among heroin addicts after the MMT program was implemented.

Additionally, the MMT program has had a significant impact on the overall HIV epidemic among drug users in China. Among newly diagnosed HIV cases, the proportion of HIV infections due to injecting drug use has decreased from almost 44% in 2003 to 7.7% in 2013 in China.

The national average HIV prevalence among drug users in sentinel surveillance declined by 50%, from 7.5% in 2005 to 3.6% in 2013.

Opportunities and challenges ahead

The rapid nationwide scale-up of China’s MMT program is the cornerstone of the response to the HIV epidemic among IDUs.

“We can attribute China’s success to four key factors,” said Dr Schwartlander. “First, strong political and financial commitment from the central government. Second, strong collaboration among health, law enforcement, and food and drug safety authorities. Third, strong processes in place to scale up and evaluate the MMT program. And fourth, the increasingly strong and positive relationship between government and civil society, an enabling environment for the program to operate within, including support from the patients’ families and wider communities.”

Dr Wu concurs, even as he lists the gaps that remain to be addressed. “Even though we’ve done so much, program coverage still remains low overall. Far too many clients still do not stick with the program. Our MMT program must better identify service gaps and continuously strive to meet the evolving needs of its clients. We have to strengthen program staff capacity, and improve the quality of service delivery. We’re still losing far too many clients -- we need to better understand their real-life challenges so that we can prevent premature deaths. And, of course, government commitment to the MMT program, and to preventing HIV among injecting drug users, must continue well into the future if the success we’ve achieved in a relatively short time is to be a long-term story.”


For more information please contact

Ms WU Linlin
WHO China Office
E-mail: wul@wpro.who.int
Office Tel: +86 10 6532 7191

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